June 201711th annual report of the PMMRC:

Reporting mortality and morbidity 2015

Lynn SadlerEpidemiologist PMMRC

Significant changes to the report 2017

• The MAT (New Zealand Maternity) dataset has been substituted for the birth registration dataset (BDM) as the denominator for all analyses

– Parity

– BMI

– Smoking

• Māori perinatal and maternal mortality

• Maternal Morbidity Working Group

Significant changes to the report 2017

• Presentation of contemporaneous (2011-2015) data in tables and figures

• Grouping of 2 yearly data

Significant changes to the report 2017

Rates 2007-2015

Perinatal related mortality rolling 3-year rates: New Zealand definitions 2007–2015

0

2

4

6

8

10

12

2007–2009 2008–2010 2009–2011 2010–2012 2011–2013 2012–2014 2013–2015

De

ath

rat

e/1

00

0 b

irth

s

Year of death

Perinatal related mortalities Neonatal deaths Stillbirths Terminations of pregnancy 2015

Perinatal related mortality rolling 3-year rates: international definitions 2007–2015

0

1

2

3

4

5

6

2007–2009 2008–2010 2009–2011 2010–2012 2011–2013 2012–2014 2013–2015

De

ath

rat

e/1

00

0 b

irth

s

Year of death

Perinatal related mortalities Neonatal deaths Stillbirths Terminations of pregnancy

Perinatal related mortality risk by gestational age at birth and year (per 1000 ongoing

pregnancies) 2007–2015

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 ≥41

Pe

rin

atal

re

late

d m

ort

alit

y ri

sk/1

00

0

on

goin

g p

regn

anci

es

Gestation at birth (weeks)

2007–2009 2010–2012 2013–2015

Perinatal related mortality risk by gestational age at birth and year (per 1000 ongoing

pregnancies) 2007–2015

22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 ≥41

Gestation at birth (weeks)

2007–2009 2010–2012 2013–2015

Why has the stillbirth rate reduced?

• Fewer births at 40+ weeks

• More iatrogenic births

• Reduced smoking, fewer mothers <20 years

• Reduced hypoxic peripartum deaths

• Maternity quality improvement (MQSP, Perinatal mortality review)

• Education around detection and management of SGA

• Sleep position

Trends in gestation at birth (36 weeks and beyond) among births in New Zealand 2007–2015

0

5

10

15

20

25

30

35

2007 2008 2009 2010 2011 2012 2013 2014 2015

Bir

ths

(%)

Year of birth

36 37 38 39 40 ≥41 weeks

Neonatal death rates 2007-2015

0

0.5

1

1.5

2

2.5

3

3.5

2007 2008 2009 2010 2011 2012 2013 2014 2015

rate

/10

00

live

bir

ths

neonatal deaths (NZ definition) neonatal deaths (international definition)

0

0.5

1

1.5

2

2.5

3

3.5

2007 2008 2009 2010 2011 2012 2013 2014

UK: NND/1000 live births from 24 weeks excluding TOPs

MBRRACE 2014 ONS data

What has happened to the neonatal death rate in other countries?

0

0.5

1

1.5

2

2.5

3

3.5

2007 2008 2009 2010 2011 2012 2013 2014

Australian neonatal death rate/1000 live births

What has happened to the neonatal death rate in other countries?

AIHW perinatal data 2014 portal

What has happened to the neonatal death rate in other countries?

Perinatal statistics in the Nordic countries 2014Neonatal deaths >=22 weeks

0

0.5

1

1.5

2

2.5

2007 2008 2009 2010 2011 2012 2013 2014

Neonatal mortality rates Scandinavia 2007-2014

Finland Iceland Norway Sweden

Recommendation

The PMMRC investigate why there has been no reduction in neonatal mortality in New Zealand

Neonatal encephalopathy rates (per 1000 term births) (three-year rolling) 2010–2015

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

2010–2012 2011–2013 2012–2014 2013–2015

NE

rate

/10

00

te

rm b

irth

s

Year of birth

Maternal mortality ratios (MMR) (per 100,000 maternities) (one-year and three-

year rolling) 2006–2015

0

5

10

15

20

25

30

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Mat

ern

al m

ort

alit

y ra

tio

/10

0,0

00

m

ate

rnit

ies

Year of death

3-year rolling MMR 1-year MMR

The MAT dataset as a denominator Contemporaneous

accurate number of births /year

Extra variables(BMI, parity, smoking)

Maternity data

Missing data Ethnicity issues

Perinatal related death rates by maternal parity 2011-2015

0

2

4

6

8

10

12

14

16

18

20

22

24

Termination of pregnancy Stillbirths Neonatal deaths Perinatal related deaths

De

ath

rat

e/1

00

0 b

irth

s

Parity 0 1 2 3 4 ≥5

Perinatal related death rates by maternal body mass index (BMI) 2011-2015

0

2

4

6

8

10

12

14

Termination of pregnancy Stillbirths Neonatal deaths Perinatal related deaths

De

ath

rat

e/1

00

0 b

irth

s

<18.50 18.50–25.49 25.50–30.49 30.50–35.49 35.50–40.49 ≥40.50

BMI (kg/m2)

Perinatal related mortality rates by smoking at registration with maternity care 2011–2015

0

2

4

6

8

10

12

14

Termination ofpregnancy

Stillbirths Neonatal deaths Perinatal relateddeaths

De

ath

rat

e/1

00

0 b

irth

s

Smoker Non-smoker

Missing registration data

• LMC, parity, BMI, smoking at registration are required data from an LMC for payment

• DHBs are bulk funded and NOT required to provide data for payment but are required to provide these data as part of service specifications

Perinatal related mortality rate by missing smoking, parity, or BMI (2008-2015)

21.09

8.92

0

5

10

15

20

25

Smoking, parity or BMI missing Smoking, parity, BMI all present

rate

/1

00

0

perinatal related mortality rate

Missing parity, smoking or BMI by ethnicity (2008-2015)

18.09

11.015.84 7.54

11.97

24.31

0

5

10

15

20

25

30

Indian Maori NZE Other OtherAsian

Pacific

% m

issi

ng

dat

a

Missing parity, BMI, or smoking by LMC at registration (2008-2015)

45.99

0.08 0.05

99.99

0.04 2.010

10

20

30

40

50

60

70

80

90

100

DHB GP MWF No LMC OBS OTHER

% m

issi

ng

dat

a

0

5

10

15

20

25

30

1 2 3 No LMC 4 5

Pe

rin

atal

re

late

d m

ort

alit

y ra

te (

/10

00

)

LMC at registration

Perinatal related mortality rate by LMC at registration (2008-2015)

Missing parity, smoking or BMI by DHB of residence (2008-2015)

0

10

20

30

40

50

60

70

% m

issi

ng

dat

a

Can we determine what the adjusted perinatal related mortality rate is for DHBs?

For ethnicity?

10.61 11.89

25.09

8.86

0

5

10

15

20

25

30

1all deaths/all births

2deaths with

missing data/births with missing

data

3all deaths/

births with nomissing data

4deaths with nomissing data/births with nomissing data

Pe

rin

atal

re

late

d m

ort

alit

y ra

te

Increased risk group

MVA with all deaths

MVA restricted to

women with data

Unadjusted analysis

What is the impact of missing data on multivariable analysis (2008-2015)?

Recommendation

The Ministry of Health urgently require DHBs to provide complete and accurate registration data to the MAT dataset (as required of LMCs providing services to pregnant women in order to receive funding…)

Missing any of smoking, parity or BMI by DHB of residence 2015

0

2

4

6

8

10

12

14

16

18

20

% m

issi

ng

dat

a

Ethnicity

• Ethnicity definition

– Registration data = parent defined at birth

– MAT = compiled from hospital discharge, LMC, NHI using prioritisation

• Numerator denominator bias

– Numerator = registration data or LMC data

– Denominator (2007-2014) = registration data

– Denominator (2015) = MAT

Perinatal related mortality rates by maternal prioritised ethnicity (with 95% CIs) 2011–2015

(MAT denominator)

0

2

4

6

8

10

12

14

16

18

20

Termination of pregnancy Stillbirths Neonatal deaths Perinatal related deaths

De

ath

rat

e/1

00

0 b

irth

s

Māori Pacific peoples Indian Other Asian Other (including unknown) NZ European

Perinatal related mortality rates by maternal prioritised ethnicity (with 95% CIs) 2011–2014

(BDM denominator)

0

2

4

6

8

10

12

14

16

18

Termination of pregnancy Stillbirths Neonatal deaths Perinatal related deaths

De

ath

rat

e/1

00

0 b

irth

s

Māori Pacific peoples Indian Other Asian Other (including unknown) NZ European

Perinatal related mortality 3year rolling rates (Māori and NZ European 2007-2015) using BDM

denominator data

0

2

4

6

8

10

12

14

2007–2009 2008–2010 2009–2011 2010–2012 2011–2013 2012–2014 2013–2015

Rat

e (

/10

00

)

Year of death

Total perinatal death - Māori - BDM denominator

Total perinatal death - NZ European - BDM denominator

Perinatal related mortality 3year rolling rates (Māori and NZ European 2007-2015) using MAT and

BDM denominator data

0

2

4

6

8

10

12

14

2007–2009 2008–2010 2009–2011 2010–2012 2011–2013 2012–2014 2013–2015

Rat

e (

/10

00

)

Year of death

Total perinatal death - Māori - MAT denominator Total perinatal death - NZ European - MAT denominator

Total perinatal death - Māori - BDM denominator Total perinatal death - NZ European - BDM denominator

Recommendation

As a matter of urgency the Ministry of Health update the MAT including ethnicity data as identified by the parents in the birth registration process (PMMRC 9th report 2015)

41 week losses 2015

41 week losses in 2015

• There were 29 perinatal losses at or beyond 41 weeks in 2015

• Of the 17 stillbirths at 41 weeks or beyond in 2015, excluding those from congenital abnormality, no antenatal risk factors were identified in 11

• Among the remaining 6, care did not follow recommended best practice

The PMMRC supports the development of a national interdisciplinary clinical practice guideline on the indications and timing for induction of labour, to guide clinicians to offer induction when appropriate (that is, where evidence shows that benefit to mother and/or baby outweighs risk) and to avoid induction when not appropriate.

Recommendation

MAORI PERINATAL AND

MATERNAL MORTALITY

“He matenga ohorere, he wairua uiui, wairua mutunga-kore.

MAORI PERINATAL MORTALITY

Unadjusted and adjusted* perinatal related mortality rates Māori and NZE 2008–2015

0

2

4

6

8

10

12

OR unadjusted OR adjusted

rate

/1

00

0

Maori-perinatal related mortality NZE-perinatal related mortality

*Adjusted for age, deprivation score, sex, multiple pregnancy, year of birth

Unadjusted and adjusted* neonatal mortality rates by Māori and NZE 2008–2015

0

0.5

1

1.5

2

2.5

OR unadjusted OR adjusted

rate

/1

00

0

Maori-NND <28 weeks NZE-NND <28 weeks

*Adjusted for age, deprivation score, sex, multiple pregnancy, year of birth

Neonatal death rate by gestation and ethnicity (Māori and New Zealand European) 2011–2015

(excluding congenital abnormalities)

Maternal mortality ratios by ethnicity (Māori and New Zealand European) 2006–2015

0

10

20

30

40

50

60

70

2006–2008 2007–2009 2008–2010 2009–2011 2010–2012 2011–2013 2012–2014 2013–2015

Rat

io (

/10

0,0

00

)

Year of death

Māori - BDM denominator NZ European - BDM denominator

MATERNAL MORTALITY

Maternal mortalities 2015

• 11 maternal mortalities 2015

– 1 AFE

– 2 VTE

– 3 pre-existing medical conditions

– 5 suicide

Recommendations for the prevention of pregnancy-associated venous thromboembolism. McLintock et al 2012:ANZJOG 52(1):3-13

Survey of multidisciplinary training in management of obstetric emergencies

• 16 DHBs provide MDT; 10 DHBs holding training in primary units

• A full day of in-house training in all but 1 unit

• 3 DHBs it is mandatory for obstetric, midwifery (core and LMC) and anaesthetics; 1 mandatory for DHB clinicians

• Cost and backfill were listed most often as barriers to attendance

Cause specific maternal mortality ratios in New Zealand 2006–2015 and the UK 2006–

2014 (with 95% CIs)

0

1

2

3

4

5

6

7

Mat

ern

al m

ort

alit

y ra

tio

/10

0,0

00

mat

ern

itie

s

NZ2006-2015 UK2006-2014

RECOMMENDATION

The PMMRC recommend the HQSC establish a permanent Suicide Review Committee

NEONATAL ENCEPHALOPATHY

NE rates by parity (2010-2015)

0.0

0.5

1.0

1.5

2.0

2.5

0 1 2 3 ≥4

NE

rate

/10

00

te

rm b

irth

s

Parity

NE audits in the 11th report

• Babies not cooled 2011-14

– 54 babies (22 severe; 32 moderate)

– 2 severe and 9 moderate babies may have benefited from cooling

• Late recognition, late consultation, late transfer

NE audits in the 11th report

• Babies not resuscitated at birth 2011-14

– 18 babies

– In 10 of these, HIE was recognised at birth on clinical grounds or cord pH

– In 7 babies, there was later presentation with NE from other causes

– One baby presented late with a diagnosis of HIE

Management of Umbilical Cord Blood Results Management of umbilical cord lactate results

Cord lactates should be taken and processed within 10 minutes of cord clamping.

Umbilical cord lactate result Action

Less than 6.0 Document results

6.0 or above Send paired umbilical cord gases

Management of umbilical cord gas results Umbilical cord gases can be analysed within one hour of birth if clamped immediately after delivery. Both umbilical cord arterial and venous gases should be analysed.

Umbilical cord gas result Action

pH less than 7.0 or base excess less than or equal to −12 mmol/L

Call paediatrician for review.

pH 7.0–7.15 or base excess −11 to −7 mmol/L Or umbilical cord gas result not available and cord lactate greater than or equal to 6.0 mmol/L

Monitor baby for signs of neonatal encephalopathy (hypotonia, poor feeding, lethargy, weak or absent suck/gag or Moro reflex, seizures). Call paediatrician if any concerns.

pH above 7.15 and base excess above −7 mmol/L

Document results.

(Auckland District Health Board 2017)

Interdisciplinary review 2016-2017

• 47 babies

• NE following an acute intrapartum event

• 2013-2015

• Reporting this year

Maternal Morbidity Working Group

ACKNOWLEDGEMENTS

• To you….

• LMCs

• DHB local coordinators

• Otago Data Group

• PMMRC and working groups

• National coordination service

• Families

• HQSC